USLME gynecologie
You are counseling a new mother and father on the risks and benefits of circumcision for their 1-day-old son. The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?
Analgesia is not recommended because there is no evidence that newborns undergoing circumcision experience pain
Analgesia is not recommended because it is unsafe in newborns
Analgesia in the form of oral Tylenol is the pain medicine of choice recommended for circumcisions
Analgesia in the form of a penile block is recommended
The administration of sugar orally during the procedure will keep the neonate preoccupied and happy.
You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?
Administration of ceftriaxone cream to the eyes for prophylaxis for gonorrhea and chlamydia
Administration of vitamin A to prevent bleeding problems
Administration of hepatitis B vaccination for routine immunization
Cool-water bath to remove vernix
Placement of a computer chip in left buttock for identification purposes
You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do. Which of the following is an accurate statement regarding breast-feeding?
Breast-feeding decreases the time to return of normal menstrual cycles
Breast-feeding is associated with a decreased incidence of sudden infant death syndrome
Breast-feeding is a poor source of nutrients for required infant growth
Breast-feeding is associated with an increased incidence of childhood obesity.
Breast-feeding is associated with a decreased incidence of childhood attention deficit disorder
A 22-year-old G1P1 who is postpartum day 2 and is bottle-feeding complains that her breasts are very engorged and tender. She wants you to give her something to make the engorgement go away. Which of the following is recommended to relieve her symptoms?
Breast binder
Bromocriptine
Estrogen-containing contraceptive pills
Pump her breasts
Use oral antibiotics
A 36-year-old G1P1 comes to see you for a routine postpartum examination 6 weeks after an uncomplicated vaginal delivery. She is currently nursing her baby without any major problems and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for birth control. She does not have any medical problems. She is a nonsmoker and is not taking any medications except for her prenatal vitamins. Which of the following methods may decrease her milk supply?
Intrauterine device
Progestin only pill
Depo-Provera
Combination oral contraceptives
Foam and condoms
A 30-year-old G3P3, who is 8 weeks postpartum and regularly breast-feeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem?
Instruct her to stop breast-feeding
Apply hydrocortisone cream to the perineum
Apply testosterone cream to the vulva and vagina
Apply estrogen cream to the vagina and vulva
Apply petroleum jelly to the perineum
A 39-year-old G3P3 comes to see you on day 5 after a second repeat cesarean delivery. She is concerned because her incision has become very red and tender and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8C (102F). Physical examination indicates that the Pfannenstiel incision is indeed erythematous and is open about 1 cm at the left corner, and is draining a small amount of purulent liquid. There is tenderness along the wound edges. Which of the following is the best next step in the management of this patient?
Apply Steri-Strips to close the wound
Administer antifungal medication
Probe the fascia
Take the patient to the OR for debridement and closure of the skin
Reapproximate the wound edge under local analgesia
A 72-year-old G5P5 presents to your office for well-woman examination. Her last examination was 7 years ago, when she turned 65. She has routine checks and laboratory tests with her internist each year. Her last mammogram was 6 months ago and was normal. She takes a diuretic for hypertension. She is a retired school teacher. Her physical examination is normal. Which of the following is the best vaccination to recommend to this patient?
Diphtheria-pertussis
Hepatitis B vaccine
Influenza vaccine
Measles-mumps-rubella
Pneumocystis
A 15-year-old woman presents to your office for her first wellwoman examination while she is on summer break from school. She denies any medical problems or prior surgeries. She had chicken pox at age 4. Her menses started at the age of 12 and are regular. She has recently become sexually active with her 16-year-old boyfriend. She states that they use condoms for contraception. Her physical examination is normal. Which of the following vaccines is appropriate to administer to this patient?
Hepatitis A vaccine
Pneumococcal vaccine
Varicella vaccine
Hepatitis B vaccine
Influenza vaccine
A 26-year-old woman presents to your office for her well-woman examination. She denies any medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contraceptive pills for birth control. Her physical examination is normal. As part of preventive health maintenance, you recommend breast self-examination and instruct the patient how to do it. Which of the following is the best frequency and time to perform breast self-examinations?
Monthly, in the week prior to the start of the menses
Monthly, in the week after cessation of menses
Monthly, during the menses
Every 3 months, in the week prior to the start of the menses
Every 6 months, in the week prior to the start of the menses
A 29-year-old woman, gravida 2, para 1, at 37 weeks gestation was admitted to the hospital. Her previous pregnancy was uncomplicated and she delivered a 3,500 g (7.7lb) baby vaginally. The current pregnancy demonstrated a breech presentation at 30 weeks gestation. A repeat ultrasonogram now shows persistent frank breech presentation with an estimated fetal weight of 2,800 g (6lb). No fetal or uterine abnormalities are noted. She has intact membranes. Examination shows a closed cervix. Fetal heart monitoring is reassuring. Which of the following is the most appropriate next step in management?
Cesarean section
External cephalic version
Internal podalic version
Allow normal vaginal delivery
Apply forceps now
A 19-year-old primigravid woman at 32 weeks gestation comes to the physician's office because of weight gain and mild generalized body swelling. She has no previous medical problems and her pregnancy has been otherwise uncomplicated. Her blood pressure is 150/90 mm Hg. Physical examination shows mild generalized edema; the remainder of her examination is unremarkable. A fetal heart tracing is reassuring. Laboratory studies show: Hematocrit: 48%, Platelets: 230,000/mm3, Serum creatinine: 1.0 g/dl, Alanine aminotransferase: 35 U/L, Urinalysis: 2+protein. Amniotic fluid analysis shows immature fetal lungs. She lives close to the hospital and is compliant with medication follow-ups. Which of the following is the most appropriate next step in management?
Recommend bed rest at home with frequent follow-up
Immediate induction of vaginal delivery
Start intravenous magnesium sulfate and admit her for close monitoring
Schedule a cesarean section as soon as possible
Start furosemide and lisinopril to prevent further edema from proteinuria
A 32-year-old woman, gravida 3, para 2, at 30 weeks gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0C (98.7F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2cm. A Nitrazine test is negative. Nonstress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?
Tocolysis
Amnioinfusion
Reassure and discharge home
Augment delivery
Cervical cerclage
A 42-year-old G4P3104 presents for her well-woman examination. She has had three vaginal deliveries and one cesarean delivery for breech. She states her cycles are regular and denies any sexually transmitted diseases. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. She drinks and smokes socially. She weighs 78 kg, and her blood pressure is 142/89 mm Hg. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient?
Intrauterine device
Bilateral tubal ligation
Combination oral contraceptives
Diaphragm
Transdermal patch
A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37C (98.4F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?
Beta-blocker
Calcium channel blocker
Diuretic
Diet, exercise, weight loss, and repeat blood pressure in 2 months
NSAID
A 32-year-old female presents for her yearly examination. She has been smoking one pack of cigarettes a day for the past 12 years. She wants to stop, and you make some recommendations to her. Which of the following is true regarding smoking cessation in women?
Ninety percent of those who stop smoking relapse within 3 months
Nicotine replacement in the form of chewing gum or transdermal patches has not been shown to be effective in smoking cessation programs
Smokers do not benefit from repeated warnings from their doctor to stop smoking
Stopping cold turkey is the only way to successfully achieve smoking cessation
No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs
A 25-year-old woman has a positive cervical culture for Neisseria gonorrhoeae. She has had at least two positive cultures for gonorrhea treated in the past. She is afebrile and has no symptoms. The incidence of penicillin-resistant gonorrhea in some areas of the United States is currently as great as 10%. Because of this, the recommended treatment for gonorrhea includes which of the following?
125 mg intramuscular ceftriaxone as a single dose
1 g spectinomycin
2 g ampicillin orally as a single dose
2 g intramuscular cefoxitin
2 g metronidazole as a single dose
A 34-year-old woman presents to the physician's office for infertility evaluation. Her cycles have been irregular for the past 12 months and she hasn't had any periods for the past 3 months. Previously, her cycles were quite regular. She also has hot flashes, dyspareunia and mood disturbances. She has been married for 6 years and has a three-year-old daughter. She has a history of Hashimoto thyroiditis and is on thyroid replacement therapy. She smokes one pack of cigarettes daily. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, and serum prolactin is normal. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?
Clomiphene citrate
Metformin
GnRH agonist
Progesterone supplement
In vitro fertilization
You are seeing a 38-year-old woman for her annual gynecologic examination. She asks you for some information regarding the HPV vaccine and whether you think it would be appropriate for her 17-year-old daughter. Which of the following statements regarding the quadrivalent human papillomavirus vaccine and HPV is true?
The vaccine is recommended for women ages 11–26 but can be given as young as age 9.
After vaccination, women no longer need routine Pap smears
The vaccine is given every month for 3 months
The vaccine is prepared from the proteins of four oncogenic (e.g., high-risk for cervical cancer) strains of HPV.
Women with a prior history of abnormal Pap smears are not candidates for vaccination
A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks’ gestation, without having noted any contractions. She is currently at 15 weeks’ gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?
Bed rest
Terbutaline
Hydroxyprogesterone
DES
A cervical cerclage
On a routine annual examination, a 43-yearold woman is found to have a 2-cm mass in the lateral aspect of her right breast. Which of the following is the most appropriate next step in management?
Repeat the breast examination after her next menses
Mammography
Fine-needle aspiration
Open biopsy
Segmental resection
A nurse called to report a low grade temperature in a 20-year-old woman who delivered a healthy baby 12 hours earlier. She had a normal vaginal delivery, and the placenta was delivered spontaneously. She had shaking chills during and ten minutes following the delivery. She continues to have bloody vaginal discharge. Her temperature is 38.0C (100.4F), blood pressure is 120/80 mmHg, pulse is 76/min and respirations are 14/min. Pelvic examination shows bloody discharge along with small blood clots on the introitus and vaginal walls. Her uterus is soft and non-tender. Laboratory studies show a WBC of 11 ,000/mm3 with 78% neutrophils. Which of the following is the most appropriate next step in management?
Reassurance
Endometrial curettage
Start empiric antibiotics
Obtain urinalysis
Culture of discharge
A healthy 32-year-old primigravid woman at 12 weeks' gestation comes for a routine prenatal visit. She has no complaints. She does not smoke or consume alcohol. She has blood group 0, Rh+ and her husband has blood group AB, Rh+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. You respond that although the child will have a blood group different from hers, alloimmunization is of little concern because?
Immune response is depressed in pregnancy
ABO antigens are weakly antigenic
Mother is tolerant to child's ABO antigens
Antibodies to ABO antigens do not cross the placenta
Antibodies to ABO antigens are not hemolytic
A 37-year-old pregnant woman has a genetic amniocentesis at 16 weeks’ gestation. A concurrent ultrasound shows normal fetal anatomy. Her prenatal course has been unremarkable. Her prenatal laboratory tests include a B negative blood type, a negative rubella antibody titer, a negative hepatitis B surface antigen, and a hematocrit of 31%. Which of the following is the most appropriate management for this woman?
Rubella immunization at the time of the amniocentesis
A serologic test for the presence of hepatitis B surface antibody
A follow-up ultrasound in 1 week to assess for intra-amniotic bleeding
Administration of Rh immune globulin at the time of the amniocentesis
Chorionic villus biopsy at the time of the amniocentesis
A 19-year-old primigravida at term has been completely dilated for 21/2 hours. The vertex is at 2 to 3 station, and the position is occiput posterior. She complains of exhaustion and is unable to push effectively to expel the fetus. She has an anthropoid pelvis. Which of the following is the most appropriate management to deliver the fetus?
Immediate low transverse cesarean section
Immediate classical cesarean section
Apply forceps and deliver the baby as an occiput posterior
Apply Kielland forceps to rotate the baby to occiput anterior
Cut a generous episiotomy to make her pushing more effective
A pregnant woman has been taking phenytoin (Dilantin) for a seizure disorder. She is concerned that the drug will cause fetal abnormalities. Which of the following defects is the most common anomaly associated with phenytoin?
Atrial septal defect
Ventricular septal defect
Cleft lip/palate
Spina bifida
Hydrocephalus
A 39-year-old woman known to have fibrocystic disease of the breast complains of persistent fullness and pain in both breasts. Which of the following drugs will be most effective in relieving her symptoms?
Tamoxifen
Bromocriptine
Medroxyprogesterone acetate
Danazol
Hydrochlorothiazide
A couple consults you because each has neurofibromatosis and wish to know what their reproductive possibilities are. You should tell them which of the following?
The disease is lethal and results in spontaneous abortion of homozygous fetuses.
25% of the females will be affected
50% of all offspring will be homozygous for the abnormal gene
75% or more of their offspring will have the disease
25% of their offspring will be unaffected
A 35-year-old woman at 30 weeks’ gestation discovers a lump in her left breast. Examination reveals a 2–3 cm, firm nodule in the upper outer quadrant. Which of the following is the most appropriate next step in the management of this patient?
Observation until after delivery
Thermography
Application of hot packs
Breast ultrasound
Fine-needle aspiration
A 1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks’ gestation. The axillary nodes are negative. Which of the following is the best management of this patient?
Terminate the pregnancy immediately and treat the breast cancer
Monitor the mass throughout pregnancy with serial breast ultrasounds
Induce labor at 34 weeks’ gestation, then give chemotherapy
Perform a cesarean delivery at 36 weeks and treat the breast cancer
Modified radical mastectomy at the time of diagnosis
A 19-year-old woman, gravida 1, para 1, is immediately status post a normal spontaneous vaginal delivery and normal third stage when she develops brisk bright red bleeding from the vagina. Her prenatal course was unremarkable. She has asthma, which worsened during the pregnancy. Ten years ago, she had a tonsillectomy. She takes a steroid and albuterol inhaler. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 115/min, and respirations are 16/min. Her abdomen is soft and non-tender. Her uterus is soft and "boggy" to palpation. Pelvic examination reveals no evidence of a laceration. Which of the following treatments should be avoided in managing this patient's postpartum hemorrhage?
Acetaminophen
IV hydration
Oxytocin
Methylergonovine
15-methyl-prostaglandin F2ct (PGF2a)
A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?
Fluoxetine
Morphine
Naloxone
Psychiatric hospitalization
Supervised visit to the nursery
A 23-year-old woman, gravida 2, para 1 at 26 weeks' gestation, comes to the physician because of fevers and pain in the middle of the back on the right side. Her fevers started 2 days ago, and the back pain began yesterday. Her temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 16/min. She has left costovertebral angle tenderness. Her abdomen is benign and gravid. Her laboratory values show leukocytes of 18,000/mm3. Urinalysis reveals white blood cells that are too numerous to count per high powered field. Which of the following is the most appropriate pharmacotherapy for this patient?
Acyclovir
Cefazolin
Levofloxacin
Metronidazole
Tetracycline
A 42-year-old woman, gravida 4, para 3, at 38 weeks' gestation, comes to the labor and delivery ward complaining of contractions. She has had type 1 diabetes since the age of 20. She has a history of syphilis that was adequately treated 4 years ago. She took insulin and prenatal vitamins throughout the pregnancy. Otherwise, her prenatal course was unremarkable, including normal screening. Her blood pressure is 140/90 mm Hg. Her cervix is 4 cm dilated and 100% effaced. She is admitted. Which of the following IV medications will this patient likely require during labor and delivery to prevent neonatal complications?
Hydralazine
Insulin
Labetalol
Meperidine
Penicillin
A 22-year-old female comes to the physician complaining of pain during sexual activity. She is unable to have intercourse because her vagina becomes tense, resulting in intense pain upon penetration. She is living with her boyfriend and this is her first sexual relationship. She now avoids intercourse because of her fear of the pain. She has no history of serious illness. Speculum examination is not possible due to tense perineal musculature. Which of the following is the most appropriate next step in management?
Advise self-stimulation techniques
Prescribe vaginal lubricants
Refer to a sex therapist
Kegel exercises and gradual dilatation
Laparoscopy to visualize endometriosis
A 19-year-old college student presents to her primary care physician for emergency contraception. She had unprotected sexual intercourse 48-hours ago while on a trip to Mexico with her boyfriend. She wants to prevent pregnancy. Her last menstrual period was 18-days ago. She has no previous medical problems. Family history is significant for migraines in her mother. She does not use tobacco, alcohol or drugs. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Tell her not to worry because the chances of getting pregnant are very low
Tell her it is too late to get emergency contraception
Administer one intramuscular injection of medroxyprogesterone
Prescribe prostaglandin E2 suppository
Administer levonorgestrel
A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 ml. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: trace, Glucose: negative, Leukocyte esterase: negative, Nitrites: negative, WBC: 1-2/hpf, RBC: 3-4/hpf. Which of the following is the most appropriate treatment for her incontinence?
Place suprapubic catheter
Place permanent Foley catheter
Do intermittent catheterization
Prescribe antibiotics
Start oxybutynin
A 54-year-old woman undergoes a laparotomy because of a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?
Excision of the omental metastasis and ovarian cystectomy
Omentectomy and ovarian cystectomy
Excision of the omental metastasis and unilateral oophorectomy
Omentectomy and bilateral salpingo-oophorectomy
Omentectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy
A 58-year-old woman is seen for evaluation of a swelling in her right vulva. She has also noted pain in this area when walking and during coitus. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Which of the following is the most appropriate treatment?
Marsupialization
Administration of antibiotics
Surgical excision
Incision and drainage
Observation
A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. The patient above now asks you for your advice on how to treat her cervical disease. Your best recommendation is for the patient to undergo which of the following?
Treatment with external beam radiation
Implantation of radioactive cesium into the cervical canal
Simple hysterectomy
Simple hysterectomy with pelvic lymphadenectomy
Radical hysterectomy
A woman is found to have a unilateral invasive vulvar carcinoma that is 2 cm in diameter but not associated with evidence of lymph node spread. Initial management should consist of which of the following?
Chemotherapy
Radiation therapy
Simple vulvectomy
Radical vulvectomy
Radical vulvectomy and bilateral inguinal lymphadenectomy
Stage Ib cervical cancer is diagnosed in a young woman who wishes to retain her ability to have sexual intercourse. Your consultant has therefore recommended a radical hysterectomy. Assuming that the cancer is confined to the cervix and that intraoperative biopsies are negative, which of the following structures would not be removed during the radical hysterectomy?
Uterosacral and uterovesical ligaments
Pelvic nodes
The entire parametrium on both sides of the cervix
Both ovaries
The upper third of the vagina
A 38-year-old woman, gravida 2, para 1, at 10 weeks gestation comes to the physician's office for prenatal counseling of genetic disorders. She has a healthy 3-year-old child. Given her age, she is worried about the risk of Down syndrome, and if her baby test is positive for Down syndrome she would like to terminate the pregnancy. Ultrasonogram shows increased fetal nuchal fold lucency. Which of the following is the most appropriate next step in management?
Chorionic villus sampling
Second trimester amniocentesis
Early amniocentesis
Cordocentesis
Maternal serum alpha fetoprotein levels (MSAFP)
57-year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the following is the most appropriate next step in management?
Ciprofloxacin for one week
Metronidazole for one week
Discontinue hydrochlorothiazide
Vaginal estrogen replacement
High-potency corticosteroid cream
A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?
Elective cesarean section at 38 weeks gestation
Use of forceps to expedite delivery
Administering HIV immunoglobulin and vaccine to the neonate
Zidovudine treatment of the mother during pregnancy and of the neonate after birth
Reassurance
A 23-year-old woman presents for evaluation of infertility. For the past 12 months she has been having sexual intercourse without contraception but has not been able to conceive. Her history is significant for irregular periods for the past 2 years. She reports exercising intensely six days per week and acknowledges having a lot of stress at work. She smokes one pack of cigarettes daily. On physical examination, her vital signs are within normal limits. Her BMI is 18 kg/m2. Urine pregnancy test is negative. Laboratory studies show: Serum FSH: low, Serum LH: low, Serum prolactin: normal, Serum TSH: normal. Which of the following therapies would be most helpful for this patient's infertility?
Anti-androgen agent
Continuous GnRH therapy
Dopamine agonist
Pulsatile GnRH therapy
In vitro fertilization
A 26-year-old G1P1 woman requests contraception after delivering a healthy baby three weeks ago. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?
Tubal ligation
Combined estrogen-progestin oral contraceptives
Coitus interruptus
Progestin-only oral contraceptives
No contraception needed while nursing
A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?
Admit to the hospital for delivery
Begin tocolysis
Intravenous penicillin
Corticosteroids
Reassure and discharge the patient home
23-year-old primigravid female at 38 weeks' gestation was admitted to the delivery room for management of labor. She was in active labor for 4-hours during which her cervical dilation progressed from 3cm to 8cm, and descent progressed from - 1 to +1 station. Examination 6-hours later showed the same degree of dilation and descent. The fetal head is in the Left Occipita Anterior (LOA) position. An external tocometer is placed and reveals contractions 3 min apart, lasting 50 seconds each. Internal pelvic assessment shows prominent ischial spines. FetaI heart monitoring shows a baseline of 140 bpm with frequent accelerations. Prenatal ultrasound at 37-weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?
Forceps application
Low-transverse C section
Administer IV Oxytocin
Close observation for 2 more hours
Zavanelli maneuver
A 16-year-old female comes to the emergency department because of heavy vaginal bleeding. She has no pain. Since menarche, menses have been irregular. She has a steady boyfriend and uses condoms for contraception. She has no other medical problems. She does not use alcohol, tobacco, or drugs. Her temperature is 37C (99F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min. Physical examination shows active vaginal bleeding. Pregnancy test is negative. Coagulation studies are within normal limits. Ultrasound shows no abnormalities. Her hemoglobin is 9.8 g/dl and hematocrit is 29%. Which of the following is the most appropriate next step in management?
Emergency dilatation and curettage
Packed red blood cell transfusion
High dose estrogen therapy
Hysteroscopy
High dose GnRH agonists
A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?
She is at risk of endometrial cancer
Her hypertension may worsen
She will develop benign breast disease
She will become diabetic
She is at risk of ovarian cancer
A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?
Nitrofurantoin for 7 days
Ciprofloxacin for 3 days
Reassurance and routine follow-up
Trimethoprim and sulfamethoxazole for 7 days
Obtain renal ultrasonogram
A 65-year-old woman is found to have osteoporosis on DEXA scan. She underwent right knee surgery five years ago and developed post-operative deep venous thrombosis, for which she was treated with 6 months of warfarin therapy. She also has severe gastroesophageal reflux disease and takes lansoprazole daily. Her mother died of breast cancer, her maternal aunt has endometrial cancer, and her paternal aunt has a history of ovarian cancer. She does not want to use bisphosphonates because of her reflux symptoms, and would like to consider raloxifene. Which of the following is a contraindication to raloxifene in this patient?
History of breast cancer in her mother
History of endometrial cancer in her maternal aunt
History of ovarian cancer in her paternal aunt
History of deep vein thrombosis
History of colon cancer
A 37-year-old obese, hypertensive female comes to the physician because of intermenstrual bleeding and heavy menses. Endometrial biopsy shows "complex hyperplasia without atypia." She has two young healthy children and does not want more children in the future. W hich of the following is the most appropriate next step in management?
Hysterectomy
Cyclic progestins
Low dose oral contraceptives
Estrogen replacement
Raloxifen
A 27-year-old nulliparous woman presents to your office complaining of a 7-week history of amenorrhea with a negative urine pregnancy test. Upon further questioning, she says that she feels fine and does not have any symptoms. She has a steady boyfriend and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any medications beside vitamin supplements to help her in her workout. She is a senior college student and works as a secretary in a law firm. On physical examination, there is no hirsutism or galactorrhea. The rest of the examination reveals nothing abnormal. Her BMI is 28 kg/m2. Initial work-up reveals the following: Serum TSH 2.5 mU/mL (N= 0.5-5.0), Prolactin 10 ng/ml (< 20 ng/ml). According to these findings, which of the following is the most appropriate next step in the management of this patient?
Determine the activity of the hypothalamus
Determine the activity of the pituitary gland
Determine the endogenous estrogen production
Determine the ovulation status
Determine the prolactin levels one week later
A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 10 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3cm dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. Fetal heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?
Augmentation of labor
Tocolysis
Cesarean section
Betamethasone IM
Expectant management
A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?
Fasting and random urine sugar
One time fasting blood sugar
75gram oral glucose tolerance test
One hour 50gram oral glucose tolerance test
Three hour 100gram oral glucose tolerance test
A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of gushing bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. She is anxious and concerned about her baby. Which of the following is the most appropriate next step in management?
Prompt induction of labor
Emergency cesarean section
Scheduled cesarean section
Forceps delivery
Conservative management at home
A 23-year-old woman who is 10 weeks pregnant with her first pregnancy is referred to you for smoking cessation. She has been smoking since the age of 21 and has never tried to quit. However, now that she is pregnant she would really like to quit. She has no symptoms of depression. Her past medical history is significant for asthma. She uses an inhaler occasionally for her asthma and takes no other medications. She has never had surgery and has no known drug allergies. Physical examination is normal for a patient at 10 weeks’ gestation. Which of the following is the most appropriate management for this patient?
Address smoking cessation after delivery
Prescribe bupropion
Prescribe fluoxetine
Prescribe the nicotine patch
Refer for smoking cessation counseling
A 42-year-old woman with hypertension and a past history of an ectopic pregnancy 18 years earlier comes to your office and reports one episode of unprotected sexual intercourse 6 days ago. Her last menstrual period was normal and occurred 2 weeks earlier. She is concerned about unintended pregnancy and asks you about the “Morning After” pill. She reports no other complaints, has been healthy recently, and her hypertension has been well controlled. She has smoked one pack of cigarettes per day for the past 20 years. Which of the following factors in this patient would be a relative contraindication to prescribing hormonal emergency contraception?
Greater than 5 days since unprotected intercourse
Age
History of ectopic pregnancy
History of hypertension
Smoking status
A 29-year-old woman, gravida 2, para 1, at 33 weeks’ gestation is referred to your office because of a possible herpes outbreak. She developed a painful vesicular rash a few days ago in her genital area. She has never before had any similar symptoms. She has no other medical problems, takes no medications, and has no known drug allergies. Examination reveals numerous erythematous vesicles and ulcerations. Testing of the lesion demonstrates herpes simplex virus infection and serologic testing reveals that it is a primary outbreak for the patient. Which of the following is the most appropriate management of this patient?
Expectant management
Immediate cesarean delivery
Immediate induction of labor
Intravenous acyclovir
Oral acyclovir
A 42-year-old woman comes to your office for an annual examination. She states that she has been feeling good over the past year. She exercises three times a week and watches her diet. She has no medical problems. She had an appendectomy at the age of 25, and no other surgeries. She uses a 35μg combined oral contraceptive pill (OCP) daily, and takes no other medications. She has been on “the pill” for birth control for the past 10 years and is happy with it. She has no known drug allergies. Physical examination, including breast and pelvic exams, is normal. She wants to know if she can continue to take the oral contraceptive pill. Which of the following is the most appropriate advice to give her?
Change from the combined OCP to hormone replacement therapy (HRT) now
Change to HRT plus aspirin now
Continue on the OCP
Stop the OCP immediately
Stop the OCP gradually over the next 3 years
A 24-year-old woman comes to your office with vaginal spotting 2 weeks after a missed menstrual period. Her past medical history is significant for pelvic inflammatory disease. She has never had surgery. She takes no medications and is allergic to penicillin. Examination demonstrates scant blood in the vaginal vault and minimal right adnexal tenderness. Laboratory evaluation reveals a beta-hCG value of 1600 mIU/mL. Blood type is O positive. Hematocrit is 39%. Pelvic ultrasound demonstrates nothing in the uterus and a right adnexal mass consistent with ectopic pregnancy. The decision is made to proceed with intramuscular methotrexate for medical treatment of the ectopic pregnancy. Which of the following is the most likely side effect from this treatment?
Alopecia
Cardiotoxicity
Infertility
Neutropenia
Stomatitis
A 4-year-old girl is brought to the physician by her mother because of a bloody, greenish, malodorous vaginal discharge. The discharge was first noted 3 days ago and has worsened since then. The girl has no other symptoms. The mother reports no concerns regarding abuse of the child. Examination is attempted but impossible because of the child's absolute refusal to be examined. Several efforts at persuasion are made but are unsuccessful. Which of the following is the most appropriate next step in management?
Reassurance and expectant management
Antibiotic administration
Police notification
Examination under anesthesia
Pelvic examination with physical restraint
A 22-year-old G3P0030 obese female comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at age 15. She has had three first-trimester voluntary pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms as well. She has a history of genital warts, but denies any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. However, 3 weeks later you receive the results of her Pap smear, which shows a high-grade squamous intraepithelial lesion (HGSIL). Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?
Young age at initiation of sexual activity
Multiple sexual partners
History of genital warts
Use of Depo-Provera
Smoking
After making a diagnosis in the patient in question 319, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?
Podophyllin
Surgical excision of the vestibular glands
Topical Xylocaine
Topical trichloroacetic acid
Valtrex therapy
A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. In the patient described in the question above, which of the following is the best treatment?
Reassurance
Oral Diflucan
Doxycycline 100 mg PO twice daily for 1 week
Ampicillin 500 mg PO twice daily for 1 week
Metronidazole 500 mg PO twice daily for 1 week
A 32-year-old women presents to the emergency room complaining of severe lower abdominal pain. She says she was diagnosed with pelvic inflammatory disease by her gynecologist last month, but did not take the medicine that she was prescribed because it made her throw up. She has had fevers on and off for the past 2 weeks. In the emergency room, the patient has a temperature of 38.3C (101F). Her abdomen is diffusely tender, but more so in the lower quadrants. She has diminished bowel sounds. On bimanual pelvic examination, bilateral adnexal masses are palpated. The patient is sent to the ultrasound department, and a transvaginal pelvic ultrasound demonstrates bilateral tubo-ovarian abscesses. Which of the following is the most appropriate next step in the management of this patient?
Admit the patient for emergent laparoscopic drainage of the abscesses
Call interventional radiology to perform CT-guided percutaneous drainage of the abscesses
Send the patient home and arrange for intravenous antibiotics to be administered by a home health agency
Admit the patient for intravenous antibiotic therapy
Admit the patient for exploratory laparotomy, TAH/BSO
A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?
Doxycycline 100 mg PO twice daily for 14 days
Clindamycin 450 mg IV every 8 hours plus gentamicin 1 mg/kg load followed by 1 mg/kg every 12 hours
Cefoxitin 2 g IV every 6 hours with doxycycline 100 mg IV twice daily
Ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 14 days
Ofloxacin 400 mg PO twice daily for 14 days plus Flagyl 500 mg PO twice daily for 14 days
A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?
Myomectomy
Total abdominal hysterectomy
Oral contraceptives
Uterine artery embolization
Oral progesterone
You see five postmenopausal patients in the clinic. Each patient has one of the conditions listed, and each patient wishes to begin hormone replacement therapy today. Which one of the following patients would you start on therapy at the time of this visit?
Mild essential hypertension
Liver disease with abnormal liver function tests
Malignant melanoma
Undiagnosed genital tract bleeding
Treated stage III endometrial cancer
A mother brings her 14-year-old daughter in to the office for consultation. The mother says her daughter should have started her period by now. She is also concerned that she is shorter than her friends. On physical examination, the girl is 4-ft 10 in tall. She shows evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You reassure the mother that her daughter seems to be developing normally. Educating the mother and daughter, your best advice is to tell them which of the following?
The daughter will start her period when her breasts reach Tanner stage 5
The daughter will start her period, then have her growth spurt
The daughter’s period should start within 1 to 2 years since she has just started developing breast buds
The daughter will have her growth spurt, then pubic hair will develop, heralding the onset of menstruation
The daughter’s period should start by age 18, but if she has not had her period by then, she should come back in for further evaluation
An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?
Ergot derivatives
Antiprostaglandins
Gonadotropin-releasing hormone (GnRH) analogues
Danazol
Codeine
A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and has a few pubic hairs starting to show up. Which of the following is the best treatment for the girl’s condition?
Exogenous gonadotropins
Ethinyl estradiol
GnRH agonists
Clomiphene citrate
No treatment; reassure the mother that pubertal symptoms at age 7 are normal
A 30-year-old female comes to the office complaining of vaginal discharge, dyspareunia and vulvar pruritus. She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol every day. On examination, you notice a thin, grayish vaginal discharge and erythema and edema of the vulva and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid which of the following during the treatment period?
Grapefruit juice
Alcohol use
Midday sun exposure
Thyroid supplements
Tobacco use
A 19-year-old woman comes to the physician for a routine physical examination. She has no complaints. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no significant past medical history and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Complete physical examination, including pelvic examination, is unremarkable. A cervical swab is sent for nucleic acid amplification of Chlamydia trachomatis and Neisseria gonorrhoeae. The nucleic acid amplification test returns positive for chlamydia infection and negative for gonorrhea. The patient is still asymptomatic. Which of the following is the most appropriate next step in management?
Repeat the test for confirmation
Reassurance and no treatment at this time
One dose of intramuscular ceftriaxone
Ceftriaxone and azithromycin
Single dose azithromycin
A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?
Metronidazole
Doxycycline
Fluconazole
Azithromycin
No therapy for now
A 20-year-old woman presents with complaints of vaginal discharge and vulvar pruritus. She has no other medical problems. Physical examination reveals a thin, malodorous vaginal discharge and erythema of the vulva and vaginal mucosa. No other exam abnormalities are noted. Wet-mount preparation of the discharge shows motile pear-shaped organisms. Which of the following management options is most appropriate?
Doxycycline for both the patient and her sexual partner
Oral metronidazole for both the patient and her sexual partner
Topical metronidazole cream for the patient only
Oral metronidazole for the patient only
Reassurance
A 28-year-old woman comes to the physician's office at 30 weeks gestation because she has not felt her baby's movements for the past week. Fetal heart tones are not heard by Doppler. An ultrasound shows an absence of fetal cardiac activity. Fetal demise is diagnosed. She underwent a cesarean section for her previous delivery to avoid a post-term pregnancy. She has no other medical problems. Vital signs are normal and physical examination shows no abnormalities. Her cervix is 3 cm dilated and 70 percent effaced. Laboratory studies show a platelet count of 230,000/mm and a fibrinogen level of 480 mg/dl (normal: 150-450mg/dl). Both the patient and her husband are shocked after hearing the news of fetal demise. Which of the following is the most appropriate next step in management?
Rush the parents to have immediate induction of labor
Admit the patient to the hospital and request psychiatry counseling
Recommend cesarean section as soon as possible
Discuss need for delivery and review options of vaginal versus cesarean
Reassurance
An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?
Leave the IUD in place without any other treatment
Leave the IUD in place and continue prophylactic antibiotics throughout pregnancy
Remove the IUD immediately.
Terminate the pregnancy because of the high risk of infection
Perform a laparoscopy to rule out a heterotopic ectopic pregnancy
A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?
The active agent in these spermicides is nonoxynol-9.
The active agent in these spermicides is levonorgestrel
Effectiveness is higher in younger users
Effectiveness is higher than that of the diaphragm
These agents are associated with an increased incidence of congenital malformations.
A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?
Clonidine
Contraceptive pill
Disruption of cervical nerve pathways
Fluoxetine
Nicotine
A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had regular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?
Dilation and evacuation (D&E)
Hypertonic saline infusion
Suction dilation and curettage (D&C)
15-methyl α-prostaglandin injection
Hysterotomy
A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?
Mammogram
Ultrasonogram
Cytologic examination
Surgical evaluation
Serum prolactin and TSH levels
A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?
Progesterone supplement
Clomiphene citrate
Dexamethasone
Dopamine agonist
In vitro fertilization
A 20-year-old, gravida 1, para 0, at 10 weeks gestation is brought to the emergency department because of moderate vaginal bleeding. She has a colicky suprapubic pain radiating to the back and denies the passage of tissue through her introitus. She does not use tobacco, alcohol or drugs. She has no history of trauma or serious illness. Her temperature is 37.0C (98.7 F), blood pressure is 100/65 mm of Hg, pulse is 90/min and respirations are 17/min. Physical examination shows a dilated cervix and the products of conception can be seen through it. Her blood type is AB Rh negative and her antibody titer is 1:2. Ultrasonogram shows a ruptured gestational sac with no fetal heart motion. Which of the following is the most appropriate next step in management?
Hospitalization, analgesics and observation
Reassurance, administration of RhoGAM and follow up
Serial beta-hCG monitoring
IV fluids, suction curettage and RhoGAM administration
Administration of a dilute infusion of oxytocin to induce labor
A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?
The level of total thyroid hormones would decrease
The metabolism of thyroid hormones would decrease
The requirement for L-thyroxine would increase
The volume of distribution of thyroxine would decrease
The level of TSH would decrease
A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?
Both vaginal delivery and cesarean delivery are acceptable.
Cesarean delivery is mandated because the fetuses are > 2000g
Cesarean delivery is mandated because the second twin is breech
Vaginal delivery is mandated because the fetuses are > 2000g
Vaginal delivery is mandated because the first twin is vertex
A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?
Observation only
Spinal magnetic resonance imaging (MRI) scan
Outpatient management with oral trimethoprim-sulfamethoxazole
Hospital admission and initiation of IV trimethoprim-sulfamethoxazole
Hospital admission and administration of a 2-week course of IV tetracycline
A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?
Prescribe a benzodiazepine
Prescribe estrogen
Prescribe haloperidol
Reassure her that time will change her feelings
Refer her for psychological counselling
A 21-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?
Azithromycin
Doxycycline
Levofloxacin
Penicillin
Streptomycin
A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?
Blood transfusion
Glucose
Naloxone
Penicillin
Sodium bicarbonate
A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?
Which alternative medications do you use?
Do you realize how dangerous alternative medicines are?
Does your husband know you are using these alternative medications?
Why don't you stick with traditional medicines?
Why haven't you revealed your use of alternative medications before?
A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother??
Breast development at age 10 is abnormally early.
Breast development at age 10 is abnormally late.
Evaluation for late menses should be started immediately.
Evaluation for late menses should be started at age 15.
Her child's sexual development is none of her business.
23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?
No treatment is necessary
Intramuscular ceftriaxone, oral doxycycline, and discharge home
Intravenous cefotetan and doxycycline and hospital admission
Intravenous clindamycin and gentamicin and hospital admission
Laparoscopy
A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?
Expectant management
Oxytocin augmentation
Forceps delivery
Vacuum delivery
Cesarean section
A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?
Folic acid, 4 mg/day starting preconceptionally
Folic acid, 4 mg/day starting in the first trimester
Vitamin A, 10,000 IU/day starting preconceptionally
Vitamin A, 10,000 IU/day starting in the first trimester
No supplements are needed
41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?
The vacuum can be used at higher stations
The vacuum can be used for fetuses in breech presentation
The vacuum can be used in face presentations
The vacuum can be used with intact membranes
The vacuum does not occupy space next to the fetal head
22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?
Administer erythromycin
Administer levofloxacin
Administer metronidazole
Administer tetracycline
Desensitize the patient and then administer penicillin
A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?
Daily oral acyclovir
Daily oral estrogen
Daily topical estrogen
Daily oral ferrous sulfate
Daily oral penicillin
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